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Moving motivation Stolte, E.
2018
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citation for published version (APA)
Stolte, E. (2018). Moving motivation: Increasing physical activity in people aged 50 and over.
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4
Chapter 4
Pilot of an Internet-based Intervention to motivate
adults aged 50+ to engage in physical activity
This chapter is co-authored by Theo G. van Tilburg and Marja J. Aartsen. We thank Renae Smith-Ray and Susan L.
Hughes from the Center for Research on Health and Aging, University of Illinois at Chicago, for their comments on drafts of the chapter, Marcel Noordzij and Vincent Osinga from the IT department of Vrije Universiteit for building the website for the Internet-based program and providing technical support throughout the program, and Matthijs Bax and Jos Bax for their feedback on the program materials, and participants for taking part in the program.
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Abstract
Objective: This brief report describes a pilot of a six-week Internet-based intervention developed for people aged 50 and over to motivate them to be more physically active. The purpose of this pilot was to assess the acceptability, feasibility, and implementation of the program.
Design: Participants were recruited via a networking website and were randomly assigned to a basic intervention group or a prompting group. The content of the physical activity (PA) intervention was almost identical for the two groups; however, the groups varied based on whether they received email prompts and based on the timing of the tips across the study period. Data were collected at baseline and at the end of the six-week program by means of online questionnaires.
Results: Nineteen out of 33 participants completed the post-measurement, and most of them rated the program favorably. The program use was reasonable, as half of the participants used all components. However, one third of participants viewed less than half of the online PA tips.
Conclusion: The program acceptability was good. With some modifications, the program would be feasible for efficacy testing with a larger sample.
4
Pilot of Internet-based PA program
Sufficient physical activity (PA) is important for the health of all people, and it is particularly im portant for older adults to age healthfully (ACSM, 2009). About a third of older adults are inactive; there fore, an increase in PA is desirable (Martinez-Gonzalez et al., 2001). Successful PA interventions for older adults have modest overall effect sizes (Conn, Valentine, & Cooper 2002). To increase the effectiveness of PA interventions Sniehotta, Scholz and Schwarzer (2005) suggested a two-phase approach where inter- ventions focus on both the intentional phase and the action phase of behavioral change.
This pilot study evaluates the acceptability and feasibility of an Internet-based motivational PA program for adults aged 50 and over. Internet-based interventions have great potential for reaching older adults using relatively few resources (Aalbers, Baars &
Olde Rikkert, 2011).
Email prompts can be used in online interventions as an intervention technique to motivate peo ple over time. Prompts are defined as “messages, reminders, or brief feedback communicated to partici pants multiple times over the duration of an intervention” (Fry & Neff 2009). Fry and Neff reviewed the use of prompts in behavior change interventions and concluded that prompts can be effective. The eff ects appear to be stronger when prompts are used more frequently and include personal contact with a counsellor. However, studies on prompting are rare.
To study the efficacy of email prompts, a six-week Internet-based motivational intervention pro gram for people over 50 was designed with and without email prompts (see Chapter 3). Adopting a two-phase approach, the Theory of Planned Behavior (Ajzen, 1991) was used as a theoretical framework to derive behavior change techniques to support intentions. Self-regulation techniques, i.e., goal setting, self-monitoring and action planning (Sniehotta, Scholz & Schwarzer, 2005), were used for the action phase of behavior. A second objective of the intervention was to study the value of video messages using an animated agent, i.e., agents with virtual bodies, in a PA intervention.
Because prompts appear to work better with personal contact (Fry & Neff 2009), an animated agent might mimic this effect.
It is important to study the acceptability and feasibility of an intervention to maximize its imple mentation and impact (Belza, Toobert, & Glasgow, 2007). The objectives of this pilot study were to as sess the implementation, acceptability and feasibility of the intervention.
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Method
Participants
Participants were recruited using an advertisement on a Dutch website for people aged 50 and over (50plusnet.nl; a social platform). Prospective participants were informed that they should be physi cally able to increase their PA and able to check their email regularly during the intervention. The regis tration procedure included informed consent and a short questionnaire. The Revised Physical Activity Readiness Questionnaire (Cardinal, Esters, & Cardinal, 1996) was used to assess contraindications for being more physically active. The exclusion criterion was sharing a household with someone already participating in the study.
Design and procedure
The pilot study used a randomized design with a standard intervention group vs.
a standard inter vention plus prompting group (i.e., prompting group). Participants were randomized to the two groups at the start of the six-week intervention.
Allocation to the groups was double-blinded. The prompting group received three prompting emails a week during weeks 3 to 6 that contained a standard message prompting participants to log into their personal page and view a new PA tip. The content of the inter vention was almost identical for the two groups; however, the PA tips were presented all at once in week 2 for the basic intervention group, while they appeared one by one each time an e-mail prompt was sent for the prompting group.
Recruitment lasted for one month, and participants started the intervention from June to July 2013. No reward for participation was given. Participants received weekly emails with a link to an online questionnaire. The evaluation of the intervention was conducted through the post-test at the end of the six-week program.
Measurement
To assess the success of the program pilot, three concepts were addressed:
acceptability, feasibil ity and implementation issues. Efficacy was not reviewed because the number of participants was small. Acceptability, which refers to participants’ appreciation of the program and the extent to which they supported or rejected it, was measured through evaluation questions, program use and dropout.
Feasi bility is a judgment made by the researchers regarding the ability to scale up the study in order to test the program’s efficacy, and it concerns practical aspects of organizing the intervention. Implementation issues were any unforeseen issues or flaws in the distribution or implementation of the program that disturbed the quality or delivery of the intervention and needed to be corrected during the pilot study or before the efficacy study started.
4
Pilot of Internet-based PA program
Questionnaires at baseline and at the end of the six-week intervention period were used. Partici pants who dropped out of the study received a brief questionnaire. As part of the post-test, participants answered questions about the six program components (i.e., two brochures and four online compo nents: PA plan, diary, text tips and video tips), including whether they had seen the component and whether they had used it, how useful each component was (1 = ‘very bad’ to 10 = ‘very good’), and how much it helped them be more physically active (1 = ‘not at all’ to 5 = ‘very much’). The four online com ponents and the male and female animated characters were evaluated in more detail on their usefulness and appearance (1 = ‘totally disagree’ to 7 = ‘totally agree’). Additional separate items assessed whether participants would recommend the program to others and why, whether they looked for extra infor mation about PA, whether they experienced technical problems playing the videos and any other re- marks about the program. People who quit the program were requested to fill out a brief questionnaire regarding the reason for starting and ending participation. Of the seven participants who left the study, three filled out this brief questionnaire.
Intervention content
The overall goal of the motivational program was to increase physical activity by increasing knowledge about and motivation for PA. Change objectives were adapted from Van Stralen et al. (2008). The Dutch physical activity recommendations (NNGB;
Kemper, Ooijendijk, & Stiggelbout 2000) were used as a guideline; these guidelines indicate that adults should engage in 30 minutes or more of moderate intense physical activity on at least five but preferably all days of the week. Brochures were used, and additional program elements were based on effective intervention strategies in the field of health be havior change that matched the performance objectives and the behavioral determinants (Abraham & Kools 2011). Table 1 shows the intervention content.
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Table 1. Intervention content of the six-week motivational program Intervention mode
and timing
Performance objectives Behavioral de terminants Intervention methods/strategies Brochures
sent by mail in week 2
1. Know how much activity they needed to meet the Dutch PA rec
ommendations 2. Know which activities
they could integrate into their daily life in order to become more active 3. Be motivated to be
more physi cally active (intention)
Knowledge/
norms
Information on PA norm, examples of activities at home or in the neighborhood, knowledge about other people’s be havior through personal stories
Outcome expec tations/
attitudes
Information on behaviorhealth links; likely physical and emotional outcomes of PA Selfefficacy Arguments that boost selfefficacy Social support Encourage people to do PA with others Barriers Address possible barriers and solutions
Website
From week 1 onwards
4. Monitor PA Knowledge/
selfmonitoring
PA diary stimulates participants to track PA and see whether they adhere to the norms Week 2 to week 6 5. Set goals and make
specific plans to be more physically active
Goal setting/
skills and selfefficacy
Online PA plan; online form including examples of activities. Steps: 1. setting goals, 2. choosing specific activities, 3. planning activities on specific days and times, 4.
registering PA, 5. thinking of healthy rewards for obtaining goals. Par ticipants also received instructions on paper.
All five performance objectives
Attitudes/
knowledge/
selfefficacy/
goal setting/
social support/
habit formation
12 PA tips in text or video with animated characters ap peared on a personal page.
For the prompting group, 12 tips appeared over the course of weeks 3 to 6 on the day that they received a prompting email. PA tips combined to form four tips for the basic intervention group appearing in week 2.
Email prompts Week 3 to week 6
All five performance objectives
Reinforcement Emails sent 3 times a week to the prompting group with standard content reminding participants of a new available PA tip on their personal page
Table 2. Appreciation of the program and its six components Grade*
(range 1-10) M (SD)
Evaluation scale (range 1-7) M (SD)
Usefulness for becoming more active (range 1-5)
M (SD)
Total program 7.2 (1.5) 3.2 (1.0)
Heart foundation brochure 7.6 (1.4) 2.9 (1.1)
Second brochure 7.3 (1.6) 2.8 (1.2)
Online PA plan 6.6 (1.6) 4.2 (1.5) 2.7 (1.1)
Online PA diary 7.1 (1.8) 4.8 (1.3) 3.0 (1.0)
Written PA tips 6.9 (1.8) 4.5 (1.1) 2.8 (1.0)
Videos with PA tips 6.9 (1.7) 4.3 (1.6) 3.0 (0.9)
* Only participants who had seen the relevant component were asked to grade it.
4
Pilot of Internet-based PA program
Results
Participant characteristics
Of 38 people who registered online, 33 started the program. Fourteen participants were allocated to the prompting group, of whom seven filled out the post-test. Seven participants left the program during the study. Of the 26 remaining participants, 19 (12 of whom were females) filled out the post-test. The mean age was 64.7 years (SD = 7.0). The educational level varied (low, n = 8; moderate, n = 6; high, n = 5).
15 Participants learned about the program through the recruiting website, three through friends and one through a web search.
Acceptability
Participants rated the total program as satisfactory (M = 7.2), with 15 out of 19 giving it a seven or higher (Table 2; according to the Dutch grading system, six is
‘sufficient’, seven is ‘satisfactory’, and eight is ‘good’). The six components received grades between ‘satisfactory’ and ‘good’. The program helped participants increase their PA (M = 3.2 on a scale where three means ‘a little’ and four means ‘some- what’). No technical problems while watching videos were reported, although one participant men tioned that the voices of the animated characters were difficult to hear. Appreciation for the animated characters (not listed in the table) was scored just above the middle of the scale (M = 4.2, SD = 1.8 and M = 4.1., SD = 1.5 for the female and male characters, respectively).
Nine out of 19 participants used all components, and all participants used some components of the program. Fifteen participants read both brochures, and 13 out of 19 used both the diary and the plan. One person viewed no tips, 14 participants viewed some tips, and four viewed all tips. Analyses of website statistics on the viewing of tips showed that half or more of the tips were viewed by nine of 12 participants in the basic intervention group and four out of seven participants in the prompting group.
Seven participants would recommend the program to others, 11 answered maybe, and one would not. One participant looked for extra information. Most participants stated that the information in the intervention was sufficient. Two themes emerged from the general remarks: four participants missed personalized feedback and expected a more personal coach-like approach, and three participants re sponded that questionnaires were taxing or boring. The reasons for quitting were that the study was too demanding or the questions were too personal.
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Implementation issues
During the pilot, it became apparent from a testing account used by the researcher that a change in settings in the email server interrupted the automatic sending of emails to participants for about a week. Additionally, at the start, tips were not visible when participants first filled out their diary. These issues were solved during the pilot.
Discussion
This pilot study showed that the intervention was acceptable and feasible, as indicated by the fa vorable ratings of the intervention and its components and the sufficient use by participants. The use of offline materials (brochures) as a supplement to an Internet-based program in this age group can be a good approach. Most participants viewed at least half of the PA tips. They expressed only mild apprecia tion for the animated characters and the PA tips in the form of animated videos. Some implementation problems became apparent and were resolved during the pilot.
The sample size was small, and not everyone filled out the evaluation. Participants who dropped out were possibly less satisfied with the program, which may have biased the positive evaluation. How ever, those who dropped out did not express dissatisfaction with the program. The program goals can be made more explicit in the future to improve expectation management. Thus, the positive evaluations provide sufficient evidence for the acceptability of the program and indicate that it is feasible to test it further with a larger number of participants.
To improve the program, revisions were made. General information on the website was changed to make it more apparent that the program does not provide personalized coaching and is targeted at participants who want to be more active. A summary of the information on the program was also sent by email to further facilitate the reading of the information. Feedback in the form of a traffic light (green, orange, red) assessment and total amount of PA per day was added to the diary. Registering and monitoring prompts is essential. Therefore, a tracking system for emails was incorporated. Moreover, to improve the chances of participants viewing the PA tips, the text and video tips were combined. Having both text and video gives participants a choice and might increase understanding among individuals who have low health literacy. A follow-up efficacy study should employ mechanisms to ensure that the PA tips are viewed. It is hypothesized that by making these changes and solving the technical issues, the rate of viewing the tips will improve. Implementation issues were identified and could be resolved be fore embarking on a larger efficacy study.
